1. COPD -Review of ‘At Risk Patient’
Mary Twitchett RGN MSc MSt (Cantab)
Advanced Nurse Practitioner
Dr Gant and Partners
114 Arbury Rd
Cambridge

2. COPD ‘At Risk’ Patients Who Are They ?
Hospital admission for COPD
> 2 Exacerbations per year
> 2 courses of steroids a year
Severe COPD
MRC score 4-5 ( ? 3)
CAT Score > 20
Mild COPD patient
COPD patient with low psychological profile
Housebound

3. Key Factors of Review
COPD review : usual review of patient as done at annual review
Assessment tools –MRC/ DOSE/ CAT score
Smoking / Inhaler technique/ Pulmonary rehabilitation
Oxygen sats when well
Self Management Plan
Exacerbation Pack
Advise out of hours
DOCUMENTATION

4. Managing stable COPD Patient with COPD Assess symptoms/problems
Manage those that are present as below
Patients with COPD should have access to the wide range of skills available from a multidisciplinary team
Smoking
Breathlessness & exercise limitation
Frequent exacerbations
Respiratory failure
Cor pulmonale
Abnormal BMI
Chronic productive cough
Anxiety & depression
Palliative care 4

5. “ Patient Myths” “My shortness of breath is just old age.”
“There’s nothing my doctor can do except tell me to quit smoking.”
“If I rest more, it will get better.”
“It’s my own fault – I don’t want to bother them “

6. Practitioners challenges
Build a relationship/ partnership
Empathy
Role with ambivalence
Challenge Thoughts
Goal set
Follow up

7. What are the questions? 7 Take-home message
The final tool contains 8 items, covering:
Cough
Phlegm
Chest tightness 
Breathlessness going up hills/stairs 
Activity limitation at home 
Confidence leaving the home 
Sleep and energy
Supporting points1
Patients read the two statements for each item, which describe the best and worst scenario, and decide where on the scale (0-5) they fit. Scores for each of the 8 items are summed to give single, final score (minimum 0, maximum 40) – this is a measure of the overall impact of a patient’s condition on their life.
Also, scores for the individual items within the questionnaire will provide insight into the relative influence that the different components of COPD have on its overall impact on a patient’s life – thus, they will highlight problematic areas, which can be explored further during consultation and ultimately addressed through intervention.
References
1 COPD Assessment Test Healthcare Professional User Guide: Expert Guidance on frequently asked questions. Jones PW, Jenkins C, Bauerle, O (on behalf of the CAT Development Steering Group). Issue 1: September 2009
Reproduced from: COPD Assessment Test Healthcare Professional User Guide 7

8. Multidisciplinary working
COPD care should be delivered by a multidisciplinary team that includes respiratory nurse specialists
Consider referral to specialist departments (not just respiratory physicians)
Specialist department
Who might benefit?
Physiotherapy
Advice about excessive sputum
Dietetic advice
People with BMI that is high, low or changing over time
Occupational therapy
People needing help with daily living activities
Social services
People disabled by COPD
Multidisciplinary palliative care teams
People with end-stage COPD (and their families and carers)
NOTES FOR PRESENTERS:
Please refer your audience page 14 of the QRG for more information on Referral for specialist advice and possible reasons for making a referral. Also, refer to page 15 of the QRG for follow-up and review of people with COPD in primary care.
Related recommendations :
The following functions should be considered when defining the activity of the multidisciplinary team:
assessing patients (including performing spirometry, assessing the need for oxygen, the need for aids for daily living and the appropriateness of delivery systems for inhaled therapy).
care and treatment of patients (including non-invasive ventilation, pulmonary rehabilitation, hospital-at-home/early discharge schemes, providing palliative care, identifying and managing anxiety and depression, advising patients on relaxation techniques, dietary issues, exercise, social security benefits and travel).
advising patients on self-management strategies
identifying and monitoring patients at high risk of exacerbations and undertaking activities which aim to avoid emergency admissions
advising patients on exercise
education of patients and other health professionals. [ ]
It is recommended that respiratory nurse specialists form part of the multidisciplinary COPD team. [ ]
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